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Andy had always been an energetic and dedicated family physician. Now, at 38, he's tired, cynical and lonely. He's angry at the health care system for forcing him to see more patients in less time and annoyed with his patients for what he perceives to be their increasingly demanding natures. Although his relationships with his patients once thrived, they no longer seem to give him the same satisfaction. Even talking to his wife, who's always been a supportive partner, has not relieved his feelings of intense isolation.

Andy has a form of burnout called compassion fatigue, a deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain. Whereas physicians with burnout adapt to their exhaustion by becoming less empathetic and more withdrawn, compassion-fatigued physicians continue to give themselves fully to their patients, finding it difficult to maintain a healthy balance of empathy and objectivity.

Those who have experienced compassion fatigue describe it as being sucked into a vortex that pulls them slowly downward. They have no idea how to stop the downward spiral, so they do what they've done since medical school: They work harder and continue to give to others until they're completely tapped out.

KEY POINTS:

Compassion fatigue is a form of burnout that manifests itself as physical, emotional and spiritual exhaustion.

To prevent or recover from compassion fatigue, take time for self-reflection, identify what's important and live in a way that reflects it.

To sustain yourself at work, develop “principles of practice” — guidelines of personal integrity that articulate the parameters of your personal values. Commit to live and work within these principles.

Causes of compassion fatigue

Compassion fatigue is flourishing today, due in part to the demands of managed care. Physicians see more patients, do more paperwork, negotiate more contracts and have less autonomy than ever before. Add to that self-imposed pressure to live up to their own high standards, and it's no wonder many physicians feel like they're going up in flames.

The medical profession, with its tremendous physical and emotional demands, naturally predisposes physicians to compassion fatigue. (To assess your state of mind, take the “Self-assessment for compassion fatigue” and see “Warning signs of compassion fatigue.”) In the past, the connection that many family physicians shared with their patients gave them the replenishment they needed to cope with the stressors of practicing medicine. But today, increasing demands have caused some physicians to stop taking the time to appreciate the love, respect and appreciation that their patients want to share with them.

Self-assessment for compassion fatigue

Answering “yes” or “no” to the following nine statements will help you assess your risk for compassion fatigue:

Answering “yes” to four or more questions may indicate that you're suffering from compassion fatigue. [This instrument, developed by the authors, has not been validated, but the results should serve as a quick check of your state of mind.] If you're interested in determining your risk for burnout, try taking the Maslach Burnout Inventory. It may be obtained through the Consulting Psychologists Press at 800-624-1765 or through their Web site at www.cpp-db.com.

Time is the enemy

To those who are in the throes of compassion fatigue, time, or more precisely the lack of it, is the enemy. To compensate, many physicians try to do several things at once (e.g., eat lunch while dictating chart notes and returning telephone calls). And to make more time, they tend to eliminate the very things that would help revitalize them: regular exercise, interests outside of medicine, relaxed meals, time with family and friends, prayer and meditation. At this point, they find it easiest to blame others. “If only,” they lament. If only the staff, system, insurance carriers, administration or their colleagues did things differently, they'd have more time. And, no matter how much or how well they sleep, they still awaken exhausted.

Hard data on compassion fatigue is admittedly difficult to come by; however, one survey found that 54 percent of office-based physicians had experienced a time when they felt they no longer had any compassion left to give, even after a restful weekend.1 Compassion fatigue takes a toll, not only on the physician, but also on the workplace, causing decreased productivity, more sick days and higher turnover.

There is hope

If you see shades of yourself in Andy, don't worry. Relief is actually nearby. To recharge your batteries you must first learn to recognize when you're wearing down and then get into the habit of doing something every day that will replenish you. That's not as easy as it sounds. Old habits are oddly comfortable even when they're bad for us, and real lifestyle changes take time (some experts say six months), energy and desire.

We guided Andy through recovery at the Center for Professional Well-Being. His first step toward overcoming compassion fatigue was to learn how to care for himself. Because physicians with severe compassion fatigue have to learn or re-establish lifestyle habits that increase their emotional resilience, we encouraged Andy to take time off from work. He took a month off and then worked part time for two more months before he began practicing again full time.

During that time, Andy started exercising again and began eliminating the junk food that he often ate while working. He spent time with friends and family he hadn't seen in recent months and took long morning walks with his wife to reconnect to the world. He even made a leisurely visit to his aging parents — a luxury he hadn't allowed himself since he was an undergraduate — and started some projects that he'd fantasized about doing “when I have time.” Never a religious person, Andy took a mindfulness meditation class that taught him how to still his mind and be present in the moment. Through it, he came to feel the presence of a higher being, something bigger than himself that he found reassuring.

Overcoming compassion fatigue means coming to terms with the anger, fear and self-doubt that some physicians have suppressed since medical school. This requires honest self-reflection, a process that some physicians find quite painful. Yet, if you're compassion fatigued, getting back in touch with yourself is perhaps the most important step in the recovery process. Without it, the lifestyle changes you're trying to make may not be enough to sustain you.

It helps to have someone to talk to who is a good listener, understands compassion fatigue, and with whom you feel a connection. This person is usually a professional counselor, but a colleague with firsthand knowledge of compassion fatigue, a pastor, or a spouse or friend who can listen without judging or offering solutions to your problems are other alternatives. A well-facilitated physician support group, although sometimes difficult to find, is also an immensely safe place. Colleagues who have learned to listen deeply can offer you caring and innovative options based on their own experiences. (For more information, see “Physician Support Groups: A Place to Turn,” October 1995, FPM, page 26.)

Warning signs of compassion fatigue

Although symptoms vary, the following red flags may indicate that you have compassion fatigue:

Abusing drugs, alcohol or food

Anger

Blaming

Chronic lateness

Depression

Diminished sense of personal accomplishment

Exhaustion (physical or emotional)

Frequent headaches

Gastrointestinal complaints

High self-expectations

Hopelessness

Hypertension

Inability to maintain balance of empathy and objectivity

Increased irritability

Less ability to feel joy

Low self-esteem

Sleep disturbances

Workaholism

If you're like most physicians, your personal identity is closely tied to your professional role. Try not to attribute compassion fatigue to a character flaw. Negative self-talk about “not having what it takes” serves no one — not you, not your family, not colleagues or patients, and most certainly not your staff members, who have probably already received a fair share of your irritability. Finally, understand that the pain of compassion fatigue is uncomfortable but normal, and that it will dissipate once you start caring for your physical and emotional needs.

Develop your own self-care plan

The lifestyle changes you choose to make will depend on your unique circumstances, but three things can speed your recovery.

Spend plenty of quiet time alone. Learning mindfulness meditation is an excellent way to ground yourself in the moment and keep your thoughts from pulling you in different directions. The ability to reconnect with a spiritual source will also help you achieve inner balance and can produce an almost miraculous turnaround, even when your world seems its blackest.

Recharge your batteries daily. Something as simple as committing to eat better and stopping all other activities while eating can have an exponential benefit on both your psyche and your physical body. A regular exercise regimen can reduce stress, help you achieve outer balance and re-energize you for time with family and friends.

Hold one focused, connected and meaningful conversation each day. This will jump start even the most depleted batteries. Time with family and close friends feeds the soul like nothing else and sadly seems to be the first thing to go when time is scarce.

Words of advice

Compassion fatigue can impair your functioning in ways that you need to keep in mind, so it comes with its own list of “don'ts”:

Don't make big decisions. We advise our compassion-fatigued clients not to make any major life decisions until they've recovered physically, emotionally and spiritually. This is perhaps the most important advice we can give. Don't quit your job, get a divorce, have an affair or spend your money on a lavish trip or a new sports car. It may feel great at the time, but a few days or weeks later you'll find yourself waking up to the same set of problems.

Don't blame others. Similarly, blaming administration, staff, colleagues or the “system” will do you no good. We've worked with several physicians who had hired attorneys and wanted to initiate legal action against their workplace. This is not the right time nor the right answer for compassion fatigue. Being adversarial will only exhaust you further and prevent the deeper healing that needs to take place. If, in the clarity of rejuvenation, you still believe legal action is appropriate, you'll be in a much better place to work with an attorney. For now, hold off. The same goes for looking for another job. Wait until you can see things more clearly and have gotten the stress in your life under control.

Don't spend your energy complaining. We also advise that you avoid commiserating with discontented colleagues. You've heard the old saying “misery loves company.” It's easy to fall into the habit of complaining when you're consumed by compassion fatigue, but it will only make you feel worse. There are other, more constructive environments to share your feelings.

Don't try a quick fix. Compassion fatigue can make you vulnerable to addictive behaviors and substance abuse. We've seen many clients try to deal with compassion fatigue by working longer and harder. Others self-medicate with alcohol and prescription drugs. There are a whole host of other addictive behaviors, including sex, that are used to relieve personal pain. Don't let yourself abuse work, alcohol or drugs and don't fall prey to a quick fix. Just as drugs can be addictive and eventually cause a whole different set of problems, the quick fix almost always ends up complicating an already overburdened life, escalating the downward spiral.

A healthier future

Clients often say to us, “It's pretty easy to take care of myself without the daily stress of work, but what happens when I get back in that pressure cooker?” The single most important thing you can do to sustain yourself once you're back at work is to develop your own “principles of practice,” a type of personal mission statement that articulates your values and identifies the parameters within which you're comfortable practicing medicine.

To create your principles of practice, ask yourself, “What gives my life joy and meaning?” This will help you identify your values and define your priorities. For example, if one of your priorities is to take better care of yourself, one of your principles may be, “I will affiliate with a group of family physicians that have clear guidelines enabling each member to take time off.” Another may be, “I will work for an organization interested in promoting professional health and satisfaction.” (For more information on identifying your personal and professional values, see “Putting ‘Life’ Back Into Your Professional Life,” June 1999, FPM.)

Commit to live and work within these principles and use them to guide your decision making. Before making decisions, pause and ask yourself, “How well will this align with my values and priorities?” You can also think of your “principles of practice” as a compass that can help you get back on track if you find that everyday stressors are steering you off course.

Andy's principles of practice described what integrity looked like in his life. Before he went back to work, he shared these principles with his partners in hopes that they would understand and support him. They had rarely talked about anything more than the day-today activities of the practice, but Andy's principles of practice gave them all something to aim toward and clarified thoughts they'd never taken the time to articulate.

Having a clear vision is essential to the next step in caring for yourself — learning to say “no.” Andy's principles of practice identified definite parameters that he knew he needed to stay within to remain healthy. These parameters freed him to start saying no without guilt to requests that didn't align with his vision. (For more information about saying “no,” see “Five Ways to Say ‘No’ Effectively,” July/August 1998, FPM.)

Andy has returned to work and continues to do what he needs to do to keep himself emotionally and physically healthy. Making appointments with himself for exercise, meditation and time with his family keeps him committed to his personal program. He treats these appointments as seriously as he does those with his patients, knowing how much his life and profession will benefit.

Where to find help

The following provide support for physicians with compassion fatigue. Call or visit their Web sites for specific information about the type of help they offer

What's important to you?

Andy's story is the tip of an iceberg that's grown rapidly in the last few years. Ten or 20 years ago, physicians who were tired of medicine and trying to transition out were 45 to 55 years old. Now, we have many 35- to 45-year-olds asking us, “Am I going to have to quit medicine to have a life outside of work?” Our answer is “no.” You can be a family physician without having to compromise your well-being. But living a balanced life does require that you take the time for self-reflection, identify what's most important to you and adopt a healthier lifestyle. This isn't something that's been taught in most medical schools, and it's not something that can wait until changes occur in the health care system.

Whether you want to prevent compassion fatigue or find your way back from it, begin to identify what's important to you. It can help you feel better about your life and your life's work.

Suggested reading

The Alchemy of Fear. Gilley K. Boston: Butterworth-Heinemann; 1998.

Leading From the Heart. Gilley K. Boston: Butterworth-Heinemann; 1997.

Dr. Pfifferling is director of the Center for Professional Well-Being in Durham, N.C., which specializes in physician stress management. He is also a clinical associate professor at the University of North Carolina, Chapel Hill.

Kay Gilley is chief executive officer of Intentional Leadership Systems in Durham, N.C., and an associate of the Center for Professional Well-Being.

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